Case Report Strongyloidiasis: The Cause of Multiple Gastrointestinal Ulcers …downloads.hindawi.com/journals/crim/2014/346256.pdf · 2019-07-31 · Case Report Strongyloidiasis:

Case ReportStrongyloidiasis: The Cause of Multiple GastrointestinalUlcers in an Immunocompetent Individual

Shail Sheth,1 Fady Asslo,1 Rabih Hallit,2 Raymund Sison,2 Muhammad Afridi,2

Robert Spira,3 Joseph DePasquale,3 Jihad Slim,2 and Jack Boghossian2

1 Department of Internal Medicine, Saint Michael’s Medical Center, Newark, NJ 07102, USA2Department of Infectious Disease, Saint Michael’s Medical Center, Newark, NJ 07102, USA3Department of Gastroenterology, Saint Michael’s Medical Center, Newark, NJ 07102, USA

Correspondence should be addressed to Shail Sheth; [email protected]

Received 21 October 2013; Accepted 20 December 2013; Published 4 February 2014

Academic Editor: Robert A. Kozol

Copyright © 2014 Shail Sheth et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Strongyloidiasis is a common parasitic disease in tropical regions of the world. Infection with Strongyloides stercoralis usuallyremains asymptomatic with peripheral eosinophilia and uncontrolled growth. Consequently, immunocompromised individualsare at a higher risk of complications of this disease. We present a case of an immunocompetent patient whose complaint of acuteabdominal pain was found to be due to gastric and duodenal ulcerations. Laboratory examination revealed significantly elevatedabsolute eosinophil count at 11,466/mm3 (normal 0–700/mm3). The duodenal biopsy revealed parasitic ova and adult wormssuggestive of Strongyloides stercoralis nematode with increased eosinophils in the tissue. We report the first case of multiple gastricand duodenal ulcerations due to Strongyloides stercoralis in an immunocompetent patient. We suggest that the elevated eosinophilcount played a central role in the pathogenesis.

1. Introduction

Global prevalence of Strongyloides stercoralis infection isunknown, but it is estimated that more than three millionpeople are infected worldwide. Infected patients usuallyremain asymptomatic with peripheral eosinophilia or maycomplain of myriad of symptoms including skin rash due tolarval penetration, cough, wheezing, dyspnea, upper abdom-inal pain, nausea, vomiting, or diarrhea. Strongyloides sterco-ralis induced gastrointestinal ulcer disease in immunocom-promised patients has beenwell described in the literature butthere is only one reported case of a gastric ulcer occurring inan immunocompetent individual due to Strongyloides sterco-ralis infection.

2. Case Report

An 83-year-old male born in Dominican Republic with apast medical history of arterial hypertension and asthmapresented with complaint of constant abdominal pain for 5

days prior to admission, located in the epigastric area. Thepatient denied having any fever, chills, nausea, emesis, oraltered bowel movements. Additionally, the patient deniedusing any inhaled corticosteroids or any other medications.He had recently returned from a trip to the DominicanRepublic one week prior to his present admission. Not beingable to recall any sick contacts, the patient on physical exam-ination was afebrile with a mildly elevated blood pressureof 142/79mmHg and a soft abdomen without any tender-ness. Initially laboratory examination was remarkable foran elevated white cell count of 18,200/mm3 (normal 4,500–11,000/mm3) with a markedly elevated absolute eosinophilcount of 11,466/mm3 (normal 0–700/mm3), while the restof his laboratory studies were unremarkable. A computedtomography scan of the abdomen was performed and wasalso unremarkable. Upper endoscopy showedmultiple ulcersin the antrum and the bulb of the duodenum. On the biopsy,parasitic ova and adult worms suggestive of Strongyloidesstercoralis with a high number of eosinophils were seen by

Hindawi Publishing CorporationCase Reports in MedicineVolume 2014, Article ID 346256, 3 pageshttp://dx.doi.org/10.1155/2014/346256

2 Case Reports in Medicine

Figure 1: Duodenal mucosa showing adult worms of Strongy-loides stercoralis associated with chronic duodenitis and increasedeosinophils (Hematoxylin and eosin stain, high power field image).

the pathologist (Figure 1). The patient was then placed onalbendazole which significantly improved his peripheraleosinophilia to a normal level.

3. Discussion

Upper gastrointestinal ulcer due to Strongyloides stercoralisinfection is a rare entity in immunocompetent patients withonly one case reported. Patientswith a compromised immunesystem are predisposed to disseminated disease that involvesmultiple systems with subsequent possible septic shock.Patients with a history of human immunodeficiency virus(HIV) or human T-lymphotropic virus (HTLV-1) infection,malignancy, current chemotherapy, corticosteroid use, mal-nutrition, chronic pulmonary diseases, diabetes mellitus,or alcoholism are at a high risk of disseminated Strongy-loides stercoralis [1] due to several mechanisms [1, 2] whichinvolve immunosuppression of eosinophilic response andlymphocytic activation against the intestinal helminth incombinationwith an altered intestinalmotility rate to create anurturing environment for Strongyloides stercoralis to matureinto an adult worm and invade the mucosal barriers ofthe gastrointestinal tract. The immune response against thehelminthic infestation is mainly controlled by the lympho-cytes, namely, the T-cell helper type 2 lymphocytes withCD4 markers (TH2 cells), that secrete important cytokines,especially Interleukin-4 (IL-4), Interleukin-5 (IL-5), andInterleukin-10 (IL-10) in response to the helminthic exposure[2]. IL-4 induces an inflammatory process that promotesmastcell recruitment and intestinal goblet cell activation whichalters gut physiology, ultimately dislodging the worm [3]. IL-5 plays a major role in the differentiation and maturationof the eosinophil, thus increasing eosinophil counts. Theeosinophils carry toxic granules which contain major basicprotein (MBP), eosinophil cationic protein (ECP), eosinophilderived neurotoxin (EDN), and eosinophil peroxidase (EPO)which are directly toxic to the larvae of Strongyloides sterco-ralis [3, 4]. ECP and EDN possess ribonuclease activity thatform pores into the membrane of target cells, facilitating theentry of other toxic molecules into the cells with subsequent

degeneration. Unfortunately, these toxic granules have cyto-toxic effects on the gastrointestinal epithelium andmay resultin ulcer formation [4].

High eosinophil counts in the serum should prompt theprovider to screen for parasitic disease. If there is still a strongsuspicion, the absence of eosinophilia is not sensitive enoughto rule out helminthic infections due to the fact that theeosinophils aremainly tissue dwelling cells [3, 4]. Eosinophilsare more numerous in tissue, a hundredfold more than in theperipheral blood. They are seen in body surfaces that havedirect interaction with the environment like the respiratorytract, gastrointestinal tract (except esophagus), and lowergenitourinary tract [3]. In a study by Loutfy et al. [5],sixty-nine of seventy-six patients positive for Strongyloidesstercoralis as diagnosed by stool tests in total had periph-eral eosinophilia. In this pool of the patients, the highesteosinophil count was 3310 eosinophil/mm3 and the medianwas 740 eosinophil/mm3 (9-10% of the total white cell count).Absolute eosinophil count in the serum has been gradedas mild (500/mm3 to 1,500/mm3), moderate (1,500/mm3 to5,000/mm3), and severe (more than 5,000/mm3). Usuallymoderate eosinophilia is required before tissue damageoccurs; however there is no reliable level that preciselyreflects the concentration of the activated eosinophils withinthe affected tissue. Our patient had total white blood cell(WBC) count of 18,200/mm3 and the manually calculatedeosinophil count was 11,466/mm3, accounting for sixty-threepercent of all WBCs, which is the highest reported numberin the literature in all strongyloidiasis cases. We suggest thatStrongyloides stercoralis nematode infection induced a dra-matic local inflammatory response in our immunocompetentpatient as indicated by absolute value of eosinophil cells.Thisextremely high number of eosinophils as a result released anincreased amount of toxic granules that produced multipleulcerations in the upper gastrointestinal tract. We reportthe first case of multiple gastric and duodenal ulcers due toStrongyloides stercoralis infection in an immunocompetentpatient with markedly elevated eosinophil cell counts and wesuggest that the eosinophil cells played a central role in thedevelopment of the ulcers.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Authors’ Contribution

All authors contributed to, reviewed, approved, and take fullresponsibility for the integrity of the final paper.

References

[1] P. B. Keiser and T. B. Nutman, “Strongyloides stercoralisin the immunocompromised population,”Clinical MicrobiologyReviews, vol. 17, no. 1, pp. 208–217, 2004.

[2] P. F. Weller, “Eosinophilia and eosinophil related disorders,” inMiddleton’s Allergy and Immunology, chapter 49, Elsevier, 7thedition, 2008.

Case Reports in Medicine 3

[3] L. Zuo and M. E. Rothenberg, “Gastrointestinal eosinophilia,”Immunology and Allergy Clinics of North America, vol. 27, no. 3,pp. 443–455, 2007.

[4] P. F.Weller, “The immunology of Eosinophils,”TheNewEnglandJournal of Medicine, vol. 324, pp. 1110–1118, 1991.

[5] M. R. Loutfy, M. Wilson, J. S. Keystone, and K. C. Kain, “Serol-ogy and eosinophil count in the diagnosis and management ofstrongyloidiasis in a non-endemic area,” American Journal ofTropical Medicine andHygiene, vol. 66, no. 6, pp. 749–752, 2002.

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Case Report Strongyloidiasis: The Cause of Multiple Gastrointestinal Ulcers …downloads.hindawi.com/journals/crim/2014/346256.pdf · 2019-07-31 · Case Report Strongyloidiasis: